The Role of Children in the Transmission of SARS-CoV-2, a Shifting Paradigm

Pediatric populations contribute to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission through a combination of exposure, susceptibility, and transmissibility. In this narrative review, SARS-CoV-2 infection in children is assessed to ascertain their role in transmission, by considering the characteristics of pediatric populations regarding their exposure and susceptibility to SARS-CoV-2 infection and COVID-19, and their transmission of the virus. A series of PubMed searches were conducted between November 2020 and February 2023 to identify articles describing SARS-CoV-2 transmission in children. The literature suggests that schools are key areas of exposure of children and adolescents to SARS-CoV-2, which contributed to school closures to mitigate spread and break transmission chains. However, the effectiveness of these measures is debated. Although SARS-CoV-2 appeared to infect children and adolescents less frequently than adults early in the pandemic, infection rates have risen considerably among the pediatric population with the emergence of variants of concern. Compared with adults and populations at high risk, children generally have a milder course of disease. The predominant role of children in transmission of SARS-CoV-2 is thought to involve household and school settings, although the relative contribution of each to transmission is questioned. Through their exposure, susceptibility, and transmissibility of SARS-CoV-2, children and adolescents are a key population contributing to the transmission of the virus. Our continued and evolving understanding of the role of children in transmission of SARS-CoV-2 has important implications to define appropriate preventive and therapeutic strategies for the pediatric population and the wider community.